Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 
x16) and home health aide services (CPT code G0156 x79). 
 
You asked the Plan to pre-approve the home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says the services are not necessary. 
 
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 the home health services. Our physician 
reviewer found the documentation does not support that the member requires skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The member does not require skilled 
nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve the 
members condition, perform a maintenance program to maintain the members condition and/or prevent 
deterioration. The member has been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The member has been taught a home exercise program. The member does not 
have need for any skilled services, and they have a paid caregiver to assist the member with custodial needs. 
The requested home health services are not 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 the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy visits (CPT code G0151 x16) and home health aide 
services (CPT code G0156 x79).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 20, 
2021. 
 
You asked the Plan to pay for the services. You say that  The Plan denied your request. The Plan says there are 
no authenticated medical records (e.g. progress notes) from the ordering physician documenting an intent for 
the clinical diagnostic test to be performed. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the test is described as a genetic-based cardiovascular risk factor screening test in which multiple genes 
are assessed. It identifies the presence of pathogenic, or likely pathogenic, variants in genes known to be 
associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this 
enrollee's clinical management. In summary, the requested testing is not considered reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on May 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2021. 
 
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. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 19, 2021. 
 
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. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 5, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there are no 
authenticated medical records from the ordering provider documenting the treating physician had intended the 
clinical diagnostic test be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physicians intent that the tests be performed. 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 August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 2021. 
 
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. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an off-campus outpatient hospital 
setting and should have been billed with POS code 19. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent observation care rendered on April 18, 2021. 
 
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. 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 99225 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 these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent 
observation care rendered on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) for post-cataract surgery 
eyeglasses purchased on September 2, 2021. 
 
You asked the Plan to pay for deluxe frames. You say that these glasses were provided for you following your 
cataract surgery and should be covered in full. The Plan denied your request. The Plan says the extra costs of 
deluxe frames are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare only covers standard frames for eyeglasses 
provided post-cataract surgery. Additional charges for deluxe frames (V2025) will be denied as non-covered.  
 
The services you asked the Plan to pay for are not covered by Original Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pay the additional cost of the deluxe frames (V2025) for post-cataract 
surgery eyeglasses purchased on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99239) provided December 22, 2020. 
 You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the billed code shares a bundled relationship with another code 
billed and is not separately 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 99239 
is a column II code to column I code 99223. 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 physician services (99239) provided December 22, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient testing (CPT code(s): 70450, 70551, 72146, 71045) 
provided on May 21, 2021. 
 
You asked the Plan to pay for the outpatient testing. You say that the services were appropriately rendered in 
response to the patients medical condition. The Plan denied your request. The Plan says that the services are 
not supported. 
 
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 70450 is computed tomography (CT), head or brain; without contrast material , 72146 is magnetic 
resonance (eg, proton) imaging (MRI), spinal canal and contents, thoracic; without contrast material, 71045 is 
radiologic examination, chest; single view, 72148 is MRI, spinal canal and contents, lumbar; without contrast 
material, and 72141 is MRI, spinal canal and contents, cervical; without contrast material. 
 
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 outpatient testing. Our reviewer found the reports support 
the documentation that each of the questioned exams was done. 
 
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 outpatient testing have been met. Therefore, we decided that the Plan has to 
pay for the outpatient testing (CPT code(s): 70450, 70551, 72146, 71045) provided on May 21, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room evaluation and management (EM) 
services provided on January 1, 2021. 
 
You asked the Plan to pay for the emergency room EM services. You say that this was not a duplicate claim as 
the enrollee was seen twice in the emergency room on this date. The Plan denied your request. The Plan says 
this was denied as a duplicate claim, and the records submitted do not reflect that two visits occurred. 
 
The Plan must follow Medicare rules. Medicare rules say that claims that are exact duplicates are denied but 
can be appealed. 
 
In this case, there is no evidence that two visits occurred on this date of service. The two progress notes 
submitted denote the exact same services and do not indicate that the enrollee was seen and then returned at a 
later time. We find that based on the information available. this claim was correctly denied as duplicate. 
Therefore, we decided that the Plan does not have to pay for the emergency room evaluation and management 
(EM) services provided on January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services rendered on August 25, 2021 to 
August 25, 2021. 
 
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 procedure code 99291 is not supported. 
 
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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
a critical care visit of 30-74 minutes 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 critical care services rendered on August 25, 2021 to August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood bank physician services rendered on April 23, 
2021. 
 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. 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 86077 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 these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the blood bank 
physician services rendered on April 23, 2021.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 more stable but is still dependent on the vent. She should 
only require short-term additional acute care services that can be safely administered at the current facility. The 
enrollee will not be able to wean from the ventilator as she is chronically dependent. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to a lower level of care may be considered when treatment has completed.  
 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been 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 daily 
skilled services are not necessary. Our physician reviewer found that you are an 87-year-old female with 
anemia, recent pelvic fractures, arial fibrillation and osteoporosis. In this case, there are no identifiable skilled 
nursing service needs. While there are identifiable skilled therapy service needs, these services are not needed 
on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility 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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on June 8, 2021. 
 
You asked the Plan to pay for the services. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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 has not clearly substantiated their reasoning to deny payment for the 
services provided on June 8, 2021. The file does not provide any clear denial of payment reason based on 
Medicare guidelines. Therefore, we decided that the Plan has to pay for the services provided on June 8, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the outpatient hospital clinic visit (G0463) provided August 31, 2021. 
 
You asked the Plan to pay for the clinic visit. You say that please reconsider the denied charges for payment 
and reprocess the claim accordingly. The Plan denied your request. The Plan says that either the service 
performed, the servicing provider or the number of visits billed do not match what was approved on the 
authorization. 
 
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. In this case specific records or information was required to substantiate the plans 
denial. The Plan indicated that an approved authorization exists but either the service performed, the servicing 
provider or the number of visits billed do not match what was approved on the authorization. A request for the 
authorization and for clarification on how the authorization has been exceeded was sent to the Plan on March 
10, 2022. The information returned was not the requested authorization that the Plan indicated was on file nor 
was there clarifying information provided. Therefore, we decided that the Plan has to pay for the outpatient 
hospital clinic visit (G0463) provided August 31, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 2021. 
 
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. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an off-campus outpatient hospital 
setting and should have been billed with POS code 19. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on July 28, 2021.
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 
August 5, 2020, to September 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the DRG was updated.  
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 432 (CIRRHOSIS AND ALCOHOLIC 
HEPATITIS 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 the documentation is insufficient to support a DRG of 432. The more appropriate DRG in this 
case would be DRG 433 (CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC).  
 
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 August 5, 2020, to September 8, 2020.