Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve five (5) physical therapy visits. We decided that the Plan does 
not have to pre-approve five (5) physical therapy visits.  
 You asked the Plan to pre-approve ten (10) physical therapy visits.. You say that these services are medically 
necessary. The Plan says that you are within normal limits for strength and getting up from sitting. 
 
We decided that the Plan has to pre-approve five (5) physical therapy visits.  
 
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 five (5) physical therapy visits. Our 
reviewer says that five (5) physical therapy visits are medically reasonable and necessary. The requested 
therapy is generally accepted as a specific and effective therapy for your weakness and incoordination after a 
stroke with hemiparesis. The most recent documentation indicated that you have made improvement in terms 
of your mobility and motor strength. You no longer require the use of single point cane when ambulating and 
your lower extremity motor strength has increased from 4 out of 5 to 4+ out of 5. You still have functional 
deficits with balance and while your Tinetti score has improved, you are at risk for falling. Therefore, 
additional therapy and the skills of a physical therapist would be appropriate to continue to meet these goals 
and transition to a home exercise program to ensure independence and minimize fall risk. This should be 
accomplishable in with 5 additional visits of physical therapy. Our physician reviewer found that your 
condition meets criteria for coverage of five (5) physical therapy visits. 
  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) physical therapy visits have been met. Therefore, we decided that the 
Plan has to pre-approve five (5) physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve five (5) physical therapy visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five (5) physical therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve five (5) physical 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN) 
(G0299) and home health aide (HHA) services (G0156). 
 
You asked the Plan to pre-approve direct skilled nursing services of an RN and HHA services. The Plan denied 
your request. The Plan says your needs can be met with a less complex service. 
 
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 direct skilled nursing services of an RN 
and HHA services. Our reviewer says that the requested HHA services are not medically necessary or 
reasonable. Our physician reviewer found you do not have documented, skilled nursing or skilled therapy 
needs. Our reviewer also found that HHA services are not shown to be needed to assist in the treatment of an 
acute illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of direct skilled nursing services of an RN and HHA services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services of a registered 
nurse (RN) (G0299) and home health aide (HHA) services (G0156).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 20930 and 22830 billed for date of service 
April 15, 2022. 
 
You asked the Plan to pay for procedure codes 20930 and 22830. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the codes billed are not eligible for separate payment. 
 
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 22830 
is a column II code to column I code 22612. This claim has not been billed with an appropriate modifier to 
bypass the edit. Procedure code 20930 has a status indicator of "B" and is not separately payable. 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 codes 20930 and 22830 billed for date of service April 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment provided on February 13, 2022, 
by an OON provider. 
 
You asked the Plan to pay for durable medical equipment. You say that you could not get the device anywhere 
else and this is the only provider that carries it.  The Plan denied your request. The Plan says you must receive 
your care from a network provider/supplier. 
 
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 durable medical equipment provided on February 
13, 2022, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT testing provided March 9, 2022. 
 
You asked the Plan to pay for the Tempus xT testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT testing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the Tempus xT testing provided March 9, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99284, an emergency department visit for the 
evaluation and management of a patient, which requires the following 3 components: a detailed history; a 
detailed examination; and medical decision making of moderate complexity provided on February 2, 2022. 
 
You asked the Plan to pay for code 99284, an emergency department visit for the evaluation and management 
of a patient, which requires the following 3 components: a detailed history; a detailed examination; and medical 
decision making of moderate complexity. You say that code 99284 meets the coding criteria. The Plan denied 
your request. The Plan says code 99284 does not meet the coding criteria. 
 
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 99284 is emergency department visit for the evaluation 
and management of a patient, which requires the following 3 components: a detailed history; a detailed examination; and medical decision making of moderate complexity. 
 
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 code 99284, an emergency department visit 
for the evaluation and management of a patient, which requires the following 3 components: a detailed history; 
a detailed examination; and medical decision making of moderate complexity. Our reviewer says that code 
99284 is not supported by the medical records. Our reviewer found that the enrollee was a then 64-year-old 
female with a history of diabetes. She presented to the emergency department with rash/urticaria. She had been 
on antibiotics x 1 2/2 weeks. She was evaluated and treated with IM steroids/Pepcid and discharged home. 
There was no decision making of high complexity. The review has determined that the use of the billed code 
99284 was not supported by the medical records. 
 
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 99284, an emergency department visit for the evaluation and management 
of a patient, which requires the following 3 components: a detailed history; a detailed examination; and medical 
decision making of moderate complexity have not been met. Therefore, we decided that the Plan does not have 
to pay for code 99284, an emergency department visit for the evaluation and management of a patient, which 
requires the following 3 components: a detailed history; a detailed examination; and medical decision making 
of moderate complexity provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82542 and 83789 billed for date of service 
December 28, 2021. 
 
You asked the Plan to pay for procedure codes 82542 and 83789. The Plan denied your request. The Plan says 
these services are not payable. 
 
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 82542 
is a column II code to column I code G0481. Based on the claim submitted, Medicare billing criteria have not 
been met. 
 
Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing 
should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for procedure codes 82542 and 83789 billed for date of service December 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93971 billed for date of service March 15, 
2022. 
 
You asked the Plan to pay for procedure code 93971. You say that you have provided additional information to 
support payment. The Plan denied your request. The Plan says payment for code 93971 is bundled into 
payment for code 93970. 
 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 93971 
is a column II code to column I code 93970. 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 93971 billed for date of service March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit, and a diagnostic 
ultrasound provided on April 4, 2022. 
 
You asked the Plan to waive the copayments for a specialist visit and a diagnostic ultrasound. You say that you 
should not have to pay an extra copayment for the ultrasound when you had to see the provider that same day, 
and they ordered it. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $45 
copayment for physician/practitioner services with a specialist and a $125 copayment for outpatient diagnostic 
tests 
 
You have been asked to pay a total copayment of $170 for a specialist visit and a diagnostic ultrasound ($45 + 
$120 = $170). A specialist visit and a diagnostic ultrasound falls within the Outpatient Diagnostic Tests and 
Physician/Practitioner Services 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 copayments for a specialist visit, and a diagnostic ultrasound 
provided on April 4, 2022.
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 and suitable for 
transfer to an LTACH. The Plan denied your request. The Plan says the LTACH admission 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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. Our reviewer 
also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 99291. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 21, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. 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 laboratory services rendered on January 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on February 7, 2022, to 
April 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the RAP claim must be submitted for home 
health services. 
 
We looked at the file and Medicare rules. The file shows that the RAP claim was not submitted for the billed 
dates of service. 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 home health services rendered 
on February 7, 2022, to April 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of a Barostim-Neo system. 
 
You asked the Plan to pre-approve a Barostim-Neo system. You say that this is medically necessary for the 
enrollees condition. The Plan denied your request. The Plan says the requested Barostim-Neo system is 
considered experimental/investigational. 
 
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 Barostim-Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered medically reasonable and necessary for the enrollee's 
condition. 
 
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 Barostim-Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the implantation of a Barostim-Neo system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 laboratory services 
rendered on January 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 19, 
2022, to May 18, 2022. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the requested service is not 
a covered benefit under Medicare. 
 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 pay for the 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 did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) care provided from April 19, 2022, to May 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service February 
22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were billed correctly. The Plan 
denied your request. The Plan says rules for payment for MDT services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 
  We looked at the file and Medicare rules. In this case, the claim for the services at issue was not submitted with 
a unique test identifier. 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 genetic testing (0037U) 
billed for date of service February 22, 2022.