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

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the services at issue are medically 
necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.   
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 inpatient psychiatric care. Our reviewer 
says that the enrollee does not meet the criteria for acute inpatient mental health treatment. Our physician 
reviewer found the enrollee did not require inpatient mental health treatment as she was not a danger to herself 
or others and did not have any delusions, auditory or visual hallucinations. It did not appear that the services 
were reasonably expected or medically necessary to improve the enrollees condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathogen identification testing billed with codes 87150, 
87481 and 87798 for date of service September 12, 2022. 
 
You asked the Plan to pay for pathogen identification testing. You say that this claim should be paid in full 
with no services denied. The Plan denied your request. The Plan says this panel was not billed in accordance 
with Medicare rules. The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of pathogen identification testing have not been met. Specifically, the records show that this was a 
single panel which was unbundled and reported with multiple codes. Therefore, we decided that the Plan does 
not have to pay for pathogen identification testing billed with codes 87150, 87481 and 87798 for date of service 
September 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you were told your benefits were approved, 
but it did not go through. The Plan denied your request. The Plan says the criteria for eligibility have not been 
met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, your provider has confirmed that you do not meet 
all the required criteria, as you have not had two or more inpatient admissions in the last 60 days, and you have 
not had three or more emergency room visits in the last 60 days. Therefore, we decided that the Plan does not 
have to pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) (E0675) and 
appliance (E0673) provided on September 14, 2022. 
 
You asked the Plan to pay for the PCD and appliance. The Plan denied your request. The Plan says this is not 
covered for use outside the home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device (PCD) (E0675) and appliance (E0673) provided on 
September 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from May 13, 2022, to 
June 1, 2022. 
 
You asked the Plan to pay for the services provided. You say that you were having trouble walking. The Plan 
denied your request. The Plan says the benefit is not covered when solely provided by an independent 
acupuncturist. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements.  We looked at the file and Medicare rules. The file does not show that the acupuncture services were furnished 
under the supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist. Based 
on this information, we decided that the rules for coverage of the acupuncture services have not been met. 
Therefore, we decided that the Plan does not have to pay for the acupuncture services provided from May 13, 
2022, to June 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prostate cancer screening (G0103) provided on 
November 14, 2022. 
 You asked the Plan to pay for the prostate cancer screening. You say that these additional screenings are 
medically necessary due to your family history and medications you take. The Plan denied your request. The 
Plan says this screening was provided in a frequency that is not covered by your plan. 
 
The Plan follows Medicare rules. You contract with the Plan says that one prostate cancer screening is covered 
every 12 months for men age 50 and older. 
 
The test at issue in this appeal, the prostate cancer screening, was provided in a frequency that is not covered 
by your plan. The record shows that you had a previous prostate cancer screening on July 7, 2022, which is less 
than 12 months before the date in question. Therefore, we decided that the Plan does not have to pay for the 
prostate cancer screening (G0103) provided on November 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart System. 
 
You asked the Plan to pre-approve The Optimizer Smart System. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is considered experimental. 
 
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 The Optimizer Smart System. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this is considered experimental. 
 
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 Optimizer Smart System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Optimizer Smart System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81272 billed for date of service September 
16, 2022. 
 
You asked the Plan to pay for procedure code 81272. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says the billed code is a statutory exclusion. 
 
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 81272 has a Status Indicator of X on the Physician Fee Schedule. This means that 
procedure code 81272 is a statutory exclusion. Based on this information, we decided that Medicare rules for 
coverage of procedure code 81272 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 81272 billed for date of service September 16, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99326 billed for September 29, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. Medicare rules say that pre-operative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. The file shows that procedure code 99326 was billed on the same day 
as minor surgical procedure 69210. Payment for code 99326 is included in the global surgical payment for code 
69210. 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 procedure code 99326 billed for September 
29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient spinal lumbar fusion surgical procedures. 
 
You asked the Plan to pre-approve lumbar fusion surgery. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
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 lumbar fusion surgery. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the records show that the enrollee is a smoker. Smoking is a contraindication to 
lumbar fusion. There must be documentation of smoking cessation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve inpatient spinal lumbar fusion surgical procedures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro orthotic device, represented by CPT code 
L8702. 
 
You asked the Plan to pre-approve MyoPro orthotic device. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
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 MyoPro orthotic device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a known diagnosis of cerebrovascular accident (CVA) in 2017 
resulting in left upper extremity weakness. The MyoPro Orthosis is not known to be effective, based on 
scientific evidence, professional standards and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for this enrollee's condition or in widespread use for this enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee.  There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. Therefore, the enrollee does not meet criteria for the requested 
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 MyoPro orthotic device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve MyoPro orthotic device, represented by CPT code L8702.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99283 billed for date of service September 24, 2022. 
 
You asked the Plan to pay for code 99283. You say that you believe this code should be paid. The Plan denied 
your request. The Plan says you did not bill this service with a modifier to indicate it is separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. Unrelated or separately identifiable visits should be billed with a 
modifier to indicate that it is a service for which separate payment may be made. 
 
In this case, you billed for a minor surgical procedure (code 12001) on the same day as code 99283.  That 
means that in order for 99283 to be paid as a separate service, it would need to be billed with an appropriate 
modifier to indicate it is a separately identifiable service.  You did not bill code 99283 with any such modifier.  
As a result, it is included in the global surgical payment for code 12001 and no separate payment can be made for code 99283.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 99283 have not been met. Therefore, we decided that the Plan does not have to pay for code 
99283 billed for date of service September 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis billed for date of service June 14, 2022. 
 
You asked the Plan to pay for the billed services. You say that you take pride in providing quality products. 
The Plan denied your request. The Plan says a valid proof of delivery was not provided. 
 
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 a valid proof of delivery for the date of service at issue. The record shows that the 
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that 
the Plan does not have to pay for the orthosis billed for date of service June 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0037U) provided on November 2, 2022. 
 
You asked the Plan to pay for the lab services. You say that this is an approved test which 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 (0037U) provided on November 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99223 provided on August 18, 2022. 
 
You asked the Plan to pay for code 99223. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the claim is 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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit.  
We find that CPT code 99223 provided on August 18, 2022. is not supported in the medical record. 
Specifically, this service was billed with a place of service 21 (inpatient hospital); however, the enrollee's 
claims history shows that this date of service the enrollee was outpatient observation status. This code cannot 
be verified as billed. Based on this information, we decided that Medicare rules for coverage of code 99223 
have not been met. Therefore, we decided that the Plan does not have to pay for code 99223 provided on 
August 18, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided October 12, 2022, to October 26, 
2022. 
 
You asked the Plan to pay for the inpatient care. You say that please see attached itemized list. The Plan denied 
your request. The Plan says that this claim cannot be reprocessed for payment until an itemized UB-04 is 
received. There is no authorization for SNF. 
 
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 were required to substantiate the Plan's denial. A 
request for the medical records was sent to the health Plan. The Plan returned an itemized statement, and no 
medical records was provided. The basis of the Plan's denial was that an itemized statement was not received. 
The Plan also denied that there is no authorization for skilled nursing facility (SNF) however, there is no 
evidence provided that the enrollee was discharged to a SNF as no medical records was provided as requested. 
Therefore, we decided that the Plan has to pay for the inpatient hospital care provided October 12, 2022, to 
October 26, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices billed for date of service 
September 12, 2022. 
 
You asked the Plan to pay for the services provided. You say that the equipment was for use during the 
enrollee's surgery. The Plan denied your request. The Plan says the devices are not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 
 The claim information shows the durable medical equipment was provided in an ambulatory surgical center.  
Although the services at issue may be helpful, neither Medicare nor the Plan covers equipment for use outside 
the home. Therefore, we decided that the Plan does not have to pay for the pneumatic compression devices 
billed for date of service September 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 you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
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 has ongoing acute medical issues and still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied by the Plan. The medical record does not indicate that the enrollee requires services 
that they are not currently receiving but that would be available at the LTACH 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.