Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PCD coded as E0652, is covered for the treatment 
of lymphedema extending onto the chest, trunk and/or abdomen when specific criteria are met. 
 
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 pneumatic compression device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the segmented pneumatic compression device (E0652) at issue 
in this case meets Medicare criteria for medically reasonable and necessary. Provided records do not document 
you have lymphedema extending onto the chest, trunk and/or abdomen. Records do not document trial and 
failure of at least four weeks of regular, daily, multiple-hour home usage of a basic pump after careful, in-
person fitting, training and supervision by a technician who is skilled in and who regularly and successfully 
uses the 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 pneumatic compression device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a pneumatic compression device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home healthcare services provided from January 3, 2022, to January 31, 2022.

You asked the Plan to pay for the home healthcare services. You say that you are requesting a claim reconsideration because an NOA was submitted to the Plan. The Plan denied your request. The Plan says Medicare no longer accepts Requests for Anticipated Payment.

The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a NOA at the beginning of the initial 30-day period of care.

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. Specifically, the documentation submitted does not include any evidence to support that a NOA was submitted at the beginning of the initial 30-day period of care. Therefore, we decided that the Plan does not have to pay for the home healthcare services provided from January 3, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 21, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sough was medically necessary to 
treat the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on March 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a COVID-19 at-home test kit provided on January 4, 2022. 
 
You asked the Plan to pay for a COVID-19 at-home test kit. The Plan denied your request. The Plan says  
at-home COVID-19 tests were not a covered benefit at the time of services. 
 
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 COVID-19 at-home test kit have not been met. Therefore, we decided that the Plan does not have 
to pay for a COVID-19 at-home test kit provided on January 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the criteria for 
admission to the Acute Inpatient Rehabilitation setting have not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation that you will 
be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthoses (L1686, L2624) provided on February 7, 
2022. 
 
You asked the Plan to pay for the hip orthoses. You say that you would like this claim reprocessed and 
approved for payment based on the documentation provided. The Plan denied your request. The Plan says the 
documentation does not support payment for the services as billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. In this case, the documentation provided does not indicate that the ordering provider discussed the medical need for the ordered orthoses with the enrollee. Therefore, we decided that the Plan does not have to 
pay for the hip orthoses (L1686, L2624) provided on February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and repair of an upper denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that you are out of state and in pain. You are 
unable to put dentures in your mouth. The Plan denied your request. The Plan says dental services from an out-
of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. The EOC confirms that your dental 
benefit does not include coverage for urgent or emergent services. The EOC also confirms that dental services 
must be performed by a participating general dentist in order to be covered. Though the Plan offers a dental 
benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when 
received from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve an 
office visit and repair of an upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an intensive 
rehabilitation program is not medically necessary. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. Our reviewer also found that there is not a reasonable expectation 
that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43239 billed on February 14, 2022. 
 
You asked the Plan to pay for procedure code 43239. You say that the medical documentation supports the 
services were rendered and the claim should be processed accordingly for payment. The Plan denied your 
request. The Plan says there is a more appropriate code for the service 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 43239 is esophagogastroduodenoscopy, flexible, 
transoral; with biopsy, single or multiple. 
 
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 procedure code 43239. Our reviewer says that the 
documentation does not support the use of procedure code 43239. Our reviewer found that there were no 
biopsy samples taken on this date of service and there is a more appropriate procedure code for the service 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 43239 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 43239 billed on February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99217 billed for date of service January 3, 
2022 to January 19, 2022. 
 
You asked the Plan to pay for procedure code 99217. The Plan denied your request. The Plan says payment for 
code 99217 is bundled into payment for code 99226.  
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 99217 
is a column II code to column I code 99226. 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 99217 billed for date of service January 3, 2022 
to January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services (81479) billed for date of service 
January 28, 2022. 
 
You asked the Plan to pay for genetic testing. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says this claim was billed with an 
incorrect date of service. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Unless a 
specific exception is met, laboratory claims should be reported with the date of service the specimen was 
collected. 
 
We find that the reported date of service of January 28, 2022, is not supported in the medical record. 
Specifically, the records indicate that the sample was collected on December 10, 2021. The limited 
documentation provided indicates that the specimen was collected by a mobile phlebotomist and not in a 
hospital setting. This means that an exception to the general rule for laboratory dates of service has not been 
met. 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 services (81479) billed for 
date of service January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on May 31, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. The 
Plan denied your request. The Plan says your benefits for the requested services have already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefits for the requested services were exhausted on date of service November 4, 2021. Therefore, 
we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of intraoral x-rays (D0210) provided on May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 9, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service April 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your care needs can be provided in a lower level of care setting. 
 
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. You 
do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 
care. Our physician reviewer found that your condition does not meet Medicare criteria for SNF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 20, 2022, to January 28, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a valid 
notice of admission (NOA) document must be submitted in order to process this claim. The documentation 
does not support that an NOA was submitted. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from January 20, 2022, to January 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve F5 (coagulation factor V) gene analysis (81241). 
 
You asked the Plan to pre-approve F5 gene analysis. You say that this test is medically necessary. The Plan 
denied your request. The Plan says this test is only covered for pregnant patients who meet certain criteria. The 
enrollee is not pregnant. 
 
The Plan must follow Medicare rules. Medicare rules say that F5 genetic testing is not considered to be 
clinically efficacious and therefore is not medically necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that F5 testing is not covered. 
Therefore, we decided that the Plan does not have to pre-approve F5 (coagulation factor V) gene analysis 
(81241).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
March 17, 2021, to March 21, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says Medicare states that for payment for DRG 871 to be covered the clinical documentation 
must support the diagnosis for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC) 
. 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
emergency physician noted that the enrollee did not show any evidence of severe sepsis, septic shock, or 
anything that was convincing for congestive heart failure. The review has determined that the records did not 
support the use of DRG 871 in this case. The records did not support the use of A41.9 - Sepsis, unspecified 
organism - in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from March 17, 2021, to March 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 22, 2021, 
through December 23, 2021 and billed with Diagnosis Related Group (DRG) 190. 
 You asked the Plan to pay for inpatient hospital services billed with DRG 190.. You say that you would like 
reconsideration because the documentation supports the DRG billed. The Plan denied your request. The Plan 
says secondary diagnosis of acute respiratory failure with hypoxia is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 190. 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 inpatient hospital services billed with DRG 190.. Our reviewer says that the 
record did not support DRG 190 with secondary diagnosis code J96.01. Our physician reviewer found 
documentation was inconsistent regarding a diagnosis of acute respiratory failure. Supporting medical record 
documentation was not found within the record. After focused initial treatment in the Emergency Department 
there was no documentation of a sustained use of accessory muscles, or altered mental status due to hypoxia. 
The enrollee admitted to having a panic attack and left against medical advice without further treatment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on December 22, 2021, through December 23, 2021 and billed with 
Diagnosis Related Group (DRG) 190.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service November 4, 
2021 to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9328. 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 of procedure code S9328 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 4, 2021 to November 5, 2021.