Persius/hicric huggingface dataset:
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. You say that it is medically necessary for the enrollee to go to 
inpatient rehabilitation. The Plan denied your request. The Plan says the records show that it is not reasonable 
to expect that the enrollee will be able to safely participate in, or fully benefit from, the intensity of services of 
an IRF. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 20, 2021, to 
May 26, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the billed DRG 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 diagnosis code J15.6. 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 inpatient hospital services at the DRG originally billed. Our 
reviewer says that the use of diagnosis code J15.6 is not supported by the records provided. Our physician 
reviewer found that the enrollee is an 81-year-old female with a past medical history including asthma, 
arthritis, diabetes mellitus, hypertension and osteoarthritis who was admitted to the hospital with shortness of 
breath and cough. She was diagnosed and treated for pneumonia that was seen on a chest x-ray. The 
documentation doesn't indicate the studies included microbiological confirmation of a gram-negative organism. 
There was no blood or sputum culture that confirmed gram-negative pneumonia. The documentation does not 
indicate that the diagnostic work-up and treatment ordered by the treating medical providers supported 
diagnosis code J15.6 (Pneumonia due to other Gram-negative bacteria).  
 
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 May 20, 2021, to May 26, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services twice a week. 
 
You asked the Plan to pre-approve skilled nursing services. You say that the requested skilled nursing services 
are medically necessary. The Plan denied your request. The Plan says the services are not medically 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 skilled nursing services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee may require assistance with activities of daily living, but this does not require skilled nursing care. 
There is insufficient documentation indicating that the enrollee was recently hospitalized, requires wound care 
or has the degree of medical acuity that would require skilled nursing services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve skilled nursing services twice a week.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on April 14, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the testing 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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's diagnosis is medication management of long term (current) drug therapy. The medical 
record sent by the provider shows presumptive screening test results which are consistent with prescription 
medications, dosing schedules, or history and expected results. There was sufficient information to manage the 
enrollee without definitive testing. The requested definitive drug testing at issue in this case is not medically reasonable or 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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on April 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has tried and failed physical 
and occupational therapy. The Plan denied your request. The Plan says the device does not meet the definition 
of medical necessity. 
 
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 requested device. Our physician 
reviewer found that the enrollee has left upper extremity partial paralysis after suffering a cerebrovascular 
accident in May 2021. The enrollee is stated to have failed physical therapy, occupational therapy, static 
bracing, and electrical stimulation. The MyoPro 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 enrollees condition or in widespread use for this enrollees condition. There is insufficient 
evidence in the literature that the MyoPro 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 request is 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro device.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing evaluation services (96133 
x4) and psychological or neuropsychological test administration and scoring (96139 x6). 
 
You asked the Plan to pre-approve neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring. The Plan denied your request. The Plan says there is no 
documentation why this extended testing time is 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 neuropsychological testing evaluation 
services and psychological or neuropsychological test administration and scoring. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has a history of cognitive/memory difficulties. The 
documentation provided is insufficient to establish the medical necessity of the requested services as ordered. 
Our reviewer found that the record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. Our 
physician reviewer also found that the requested services are not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing evaluation services and psychological or 
neuropsychological test administration and scoring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neuropsychological testing evaluation services (96133 x4) and psychological or 
neuropsychological test administration and scoring (96139 x6).
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 has no diet and will not be 
accepted in the local facilities without this set up and has been inpatient for 39 days so far and needs to 
continue with continuous care from medical personal. The Plan denied your request. The Plan says the 
enrollee's continued care needs include nutrition management, skilled nursing care, and skilled rehabilitation. 
When ready to leave the hospital, the enrollee may safely receive this care in another setting, such as a skilled 
nursing facility. 
 
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 requested LTACH services are not 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 the anesthesia services (01924) provided on June 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says code 01924 is 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. 
 
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 services. Our reviewer says that the use of code 01924 is 
not supported by the records provided. Our reviewer found that the medical records do not support the use of 
an additional anesthesia code of 01924 for anesthesia for IR procedures. The use of anesthesia for the 
procedures performed is indicated in anesthesia code 01770. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services (01924) provided on June 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing of 22 or more classes provided on 
September 2, 2022. 
 
You asked the Plan to pay for the drug testing of 22 or more classes. You say that this testing should be 
covered. The Plan denied your request. The Plan says the records do not support that 22 or more classes were 
tested. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
21 classes of drugs were tested. Based on this information, we decided that Medicare rules for coverage of the 
drug testing of 22 or more classes have not been met. Therefore, we decided that the Plan does not have to pay 
for the definitive drug testing of 22 or more classes provided on September 2, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that these services were authorized. The Plan 
denied your request. The Plan says procedure code 97010 is considered bundled and 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 procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service October 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar wedge pillow (E1399) and cervical wedge pillow 
(E1399), provided on July 13, 2022. 
 
You asked the Plan to pay for the pillows. You say that the items are medically necessary. The Plan denied 
your request. The Plan says these items do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the lumbar wedge pillow (E1399) and cervical wedge pillow 
(E1399), provided on July 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on February 12, 
2022, to February 19, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. The Plan denied your 
request. The Plan says the diagnosis was not consistent with the documentation. 
 
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.   
 
We find that the inpatient services were billed with diagnosis code N17.0, defined as acute renal failure with 
tubular necrosis. 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 inpatient hospital 
services at the DRG originally billed. Our physician reviewer found that the enrollee presented to the 
emergency room for a left hip wound check. The wound was irrigated and debrided. The submitted 
documentation indicate that creatinine recorded on during hospital stay range from 1.3 - 1.5 mg/dL. The 
urinalysis shows the urine appearance as yellow and clear with traces of protein. The recovery phase, in which 
tubular function recovers, is characterized by an increase in urine volume and by a gradual decrease in blood 
urea nitrogen (BUN) and serum creatinine to their preinjury levels. In this case, there was no evidence of non-
hyaline cast present in the urinalysis, a urinary sodium over 40 mEq/L, FeNA over 2%, or renal biopsy 
confirmation to support the diagnosis. Therefore, the review has determined that the documentation did not 
support the billed diagnosis code. 
 
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 the inpatient hospital services provided on February 12, 2022, to February 19, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on May 2, 2022. 
 
You asked the Plan to pay for ambulance services. You say that the claim was partially paid and partially 
denied. You say that you would like the medical records reviewed for necessity. The Plan denied your request. 
The Plan says original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on May 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from January 30, 2022 to 
June 28, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you submitted the required 
NOA. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from January 30, 2022 to June 
28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services (90999, Q4081) provided on June 1, 2022 to 
June 29, 2022. 
 
You asked the Plan to pay for the dialysis services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 90999, & Q4081 are not supported in the medical record. Specifically, the services 
were not billed with a required JA modifier. Based on this information, we decided that Medicare rules for 
coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay 
for dialysis services (90999, Q4081) provided on June 1, 2022 to June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (80053, 80061, 84443 and 85025) 
provided on May 17, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services are supported as billed. The Plan 
denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the medical records provided only include an order form for these tests. There are no results 
included in the records to support that these services were provided as billed. Therefore, we decided that the 
Plan does not have to pay for laboratory services (80053, 80061, 84443 and 85025) provided on May 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on August 7, 2020. 
 
You asked the Plan to pay for the lab testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab testing was not filed until June 15, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab testing provided on August 7, 2020.