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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the services would give you a chance of getting 
better and coming home sooner. The Plan denied your request. The Plan says the criteria for a skilled nursing 
facility is not met. 
  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 you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483 and 80307) provided on June 6, 
2022. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
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 G0483 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; 22 or 
more drug class(es), including metabolite(s) if performed.  
We find that CPT code G0483 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; 22 or more drug class(es), including 
metabolite(s) if performed is not supported in the medical record. Review of the documentation does not 
support 22 or more drug classes, only 11 drug classes were tested. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing (G0483 and 80307) provided on June 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient hospital services provided on 
July 17, 2022, to July 19, 2022. 
 
You asked the Plan to waive the deductible for outpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $101.91 
deductible for outpatient hospital observation.  
 
You have been asked to pay $101.91 deductible for outpatient hospital services. This item/service falls within 
the outpatient hospital observation benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the deductible for 
outpatient hospital services provided on July 17, 2022, to July 19, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services billed for dates of service from June 12, 2022, to 
July 11, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the HHA notifies Medicare systems via 
submission of an NOA. Only one NOA is required for any series of HH periods of care beginning with 
admission to home care and ending with discharge. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have been met. Specifically, the case record indicates that the episode of care 
at issue is not the initial episode of care and does not require submission of an NOA specific to the episode of 
care. Therefore, we decided that the Plan has to pay for home health services billed for dates of service from 
June 12, 2022, to July 11, 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: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided from June 10, 2021, to July 1, 2021. 
 
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied 
your request. The Plan says that this claim was not coded correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that they received medical records, but none were included in the 
case file. Without this information, it cannot be confirmed that this claim was coded incorrectly. Therefore, we 
decided that the Plan has to pay for home health services provided from June 10, 2021, to July 1, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from July 5, 2022, to July 15, 
2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and reasonable. The Plan denied your request. The Plan says that this inpatient stay was not 
medically necessary, and the enrollee was only pre-approved for outpatient observation care from July 5, 2022, 
to July 7, 2022. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee with a history of Alzheimers disease was admitted via Emergency Department 
(ED) on July 5, 2022, with a Urinary Tract Infection (UTI), Altered Mental Status (AMS), Dehydration and 
Failure to Thrive. Treatment included intravenous (IV) fluids and IV antibiotics. The review indicates that the 
record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
enrollees 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from July 5, 2022, to July 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound, breast, unilateral, real time with image 
documentation, including axilla when performed; limited (76642) provided on September 21, 2022. 
 
You asked the Plan to pay for the breast ultrasound. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 the breast ultrasound have not been met. CPT code 76642 26 LT 
and 76642 26 RT was not billed in accordance with Medicare National Correct Coding Initiative Policy MUE. 
This is not a medical necessity denial. We determined that our original decision to deny payment is correct. 
CPT code 76642 26 LT and 76642 26 RT is not billed in accordance with Medicare National Correct Coding 
Initiative Policy. This is not a medical necessity denial. CPT code 76642 26 LT and 76642 26 RT has an MUE 
value of 1, but billed 2 units. Therefore, we decided that the Plan does not have to pay for the ultrasound, 
breast, unilateral, real time with image documentation, including axilla when performed; limited (76642) 
provided on September 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 13, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these tests were medically necessary and should 
be paid. The Plan denied your request. The Plan says there was not enough information provided to process this 
claim. 
 
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 laboratory services have been met. 
Specifically, the results of these tests were not provided, so it cannot be verified that the services were provided as billed. Also, no progress notes or physician order were provided to support the medical necessity of these 
tests. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 13, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says 12 additional physical therapy 
visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that you do not require the unique skills of a professional therapist to 
safely and effectively provide treatment. The services can be safely and effectively performed only by a 
therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, 
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design, or 
deliver a program to maintain your current condition to prevent or slow further deterioration. You can 
transition to an independent home exercise program and does not require the ongoing skills of a professional 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99232, 99239, 99223, 99233) provided 
on August 12, 2022 to August 15, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
We find that CPT code 99232, 99239, 99223, & 99233 is not supported in the medical record. Specifically, the 
claim was not billed with a valid primary diagnosis. Based on this information, we decided that Medicare rules 
for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to 
pay for physician services (99232, 99239, 99223, 99233) provided on August 12, 2022 to August 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on July 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services should be paid. 
The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory 
testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on July 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on April 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. 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 April 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the admission to a LTACH is not medically 
necessary. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 14, 2022, 
through May 31, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
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 the home health services have not been met. As per Medicare 
guidelines the missing data was a 0023 revenue code with an associated HIPPS code. The claim was also 
missing appropriate G and Q codes for the billed dates of service. Therefore, we decided that the Plan does not 
have to pay for the home health services provided from January 14, 2022, through May 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided February 
1, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was treated for post-
surgical edema/inflammation and post-surgical lymphedema. You disagree with this denial and believe these 
services were medically necessary. 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 February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 64999 and 69990 for services provided on June 28, 
2022. 
 
You asked the Plan to pay for codes 64999 and 69990. 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. 
 
In this case, the CPT Code Manual definition of code 64999 is unlisted procedure, nervous system. 
 
In this case, the CPT Code Manual definition of code 69990 is microsurgical techniques, requiring use of 
operating microscope (List separately in addition to code for primary procedure). 
 
We find that CPT code 64999 and 69990 is not supported in the medical record. Specifically, the 
documentation does not support that code 64999 billed is for the surgical procedure performed. In addition, 
with code 64999 being denied, we have confirmed that code 69990 is an add-on code and has not been billed 
with an appropriate primary procedure code. Based on this information, we decided that Medicare rules for 
coverage of codes 64999 and 69990 have not been met. Therefore, we decided that the Plan does not have to 
pay for codes 64999 and 69990 for services provided on June 28, 2022.