Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not ready to be discharged from the current 
facility. The Plan denied your request. The Plan says that SNF care is no longer medically necessary. 
 
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. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
September 10, 2022. 
 
You asked the Plan to pay for the blood smear services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are 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 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code has an indicator of 
"8". This code was billed with place of service 22 (on campus-outpatient hospital). No payment is recognized 
for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this information, we decided 
that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided that the 
Plan does not have to pay for the blood smear services coded 85060 provided on September 10, 2022.
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 June 
24, 2021, to July 1, 2021. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
should be paid for. The Plan denied your request. The Plan says the removal of the diagnosis codes and change in DRG is based on lack of supporting clinical evidence from the medical record provided and not based solely 
on coding guidelines. 
 
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. 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 services at issue in this case were not supported by the medical records. Our physician reviewer found 
that the documentation does not indicate that the treatment ordered by the treating medical providers supported 
multiple diagnosis codes including A41.9 (Sepsis, unspecified organism) and G93.41(metabolic 
encephalopathy). In this case, the documentation does not consistently and completely support multiple 
diagnosis codes including sepsis, aspiration pneumonia, metabolic encephalopathy or acute respiratory 
failure. The enrollee was treated for acute congestive heart failure however, the decision to remove multiple 
diagnosis codes and adjust the DRG is upheld.  
 
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 June 24, 2021, to July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97810, 97811) provided on January 
19, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage rules are not met, and this claim is a duplicate. 
 
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, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provided records show this service was for hip 
pain. Insufficient documentation was provided to show this service was for chronic lower back pain. 
Additionally, this claim is a duplicate of a claim previously considered for payment. Therefore, we decided that 
the Plan does not have to pay for acupuncture services (97810, 97811) provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on July 
26, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was prescribed following surgery to prevent 
thrombotic events. You said that this item should be covered. The Plan denied your request. The Plan says this 
item is not covered. The Plan must follow Medicare rules. Medicare rules say that PCDs used for the 
prevention of thrombotic events are explicitly non-covered.  The records and your appeal letter confirm that the 
PCD at issue in this case was provided solely for the prevention of thrombotic events following surgery. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) 
provided on July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
September 6, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was prescribed following surgery to prevent 
thrombotic events. You said that this item should be covered. The Plan denied your request. The Plan says this 
item is not covered. The Plan must follow Medicare rules. Medicare rules say that PCDs used for the 
prevention of thrombotic events are explicitly non-covered.  The records and your appeal letter confirm that the 
PCD at issue in this case was provided solely for the prevention of thrombotic events following surgery. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) 
provided on September 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) provided on 
August 16, 2022. 
 
You asked the Plan to pay for the PCD. You say that this item was prescribed following surgery to prevent 
thrombotic events. You said that this item should be covered. The Plan denied your request. The Plan says this 
item is not covered. The Plan must follow Medicare rules. Medicare rules say that PCDs used for the 
prevention of thrombotic events are explicitly non-covered.  The records and your appeal letter confirm that the 
PCD at issue in this case was provided solely for the prevention of thrombotic events following surgery. 
Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (PCD) 
provided on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator, with integrated 
electrocardiogram analysis, garment type (K0606) provided October 4, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that please review and reconsider 
this claim for payment. You are asking for extension of the timely filing limit as the transition in the 
authorization process delayed this claim. The Plan denied your request. The Plan says the claim was submitted 
past the timely filing limitation. 
 
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 automatic external defibrillator was not filed until November 11, 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 automatic external defibrillator, with 
integrated electrocardiogram analysis, garment type (K0606) provided October 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing that was done on October 27, 2022, billed with 
procedure code 93010. 
  
You asked the Plan to pay for Electrocardiogram, routine ECG with at least 12-leads; interpretation and report 
only.. You say that per centers for Medicare & Medicaid Services, the medically unlikely edit is 5 per day. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 01, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. Based on this information, we decided that the Medicare rules for Electrocardiogram, routine ECG with at least 
12-leads; interpretation and report only. have not been met. Therefore, we decided that the Plan does not have 
to pay for testing that was done on October 27, 2022, billed with procedure code 93010.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service October 23, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the member had multiple exams done on 
this date of service. 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 October 23, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 15, 2021, to September 19, 2021. 
 
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 documentation does not support that the enrollee was provided a mechanically altered diet. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the correct PDPM was submitted by the skilled nursing facility. There is no indication that the 
enrollee received or required a mechanically altered diet and that the 2nd alphanumeric character in the PDPM 
was correct. The partial adjustment to PDPM KDGD1 was appropriate. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from September 15, 2021, to 
September 19, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the prostate cancer screening; prostate specific antigen test (PSA) 
(G0103) provided on July 1, 2022. 
 
You asked the Plan to pay for the prostate cancer screening. You say that your last prostate cancer screening 
was over 12 months ago, and this test should be covered. The Plan denied your request. The Plan says that this 
service is denied. 
 
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 rules say that PSA tests are covered once every 12 months for men who have attained age 50 (at 
least 11 months have passed following the month in which the last Medicare-covered screening prostate 
specific antigen test was performed). 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a clear reason for denial with a 
supporting citation and evidence. Your argument indicates that the Plan originally denied this claim stating that 
you have had a PSA test within the last 12 months; however, the limited documentation in the case file 
indicates that your last PSA screening was collected and resulted on June 21, 2021, which is more than 12 
months before the date in question. The Plan has failed to substantiate any reason for denial in this case. 
Therefore, we decided that the Plan has to pay for the prostate cancer screening; prostate specific antigen test 
(PSA) (G0103) provided on July 1, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation. 
 
You asked the Plan to pre-approve Transcranial Magnetic Stimulation. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Transcranial Magnetic Stimulation is covered for 
Major Depressive Disorder when medically necessary. 
 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 Transcranial Magnetic Stimulation. Our 
reviewer says that this service is not medically necessary. Our physician reviewer found the provided records 
do not show that the enrollee has the severity of illness to require this type of treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Transcranial Magnetic Stimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Transcranial Magnetic Stimulation.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81599) provided 
March 13, 2022. 
 
You asked the Plan to pay for the unlisted procedure. You say that the Nodify CDT blood-based test was 
ordered to determine whether this enrollee was high risk for malignancy prior to performing an invasive biopsy 
or surgery. The Plan denied your request. The Plan says The additional documentation requested for review 
was not submitted within the timeframe established by CMS. 
 
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 the unlisted procedure have been met. 
additional information was required. The records show that the additional information that was requested was 
not received. Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology 
procedure (81599) provided March 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) provided on August 24, 
2022. 
 
You asked the Plan to pay for drug testing. You say that this testing was medically necessary and was ordered 
by the enrollee's physician. The Plan denied your request. The Plan says this service was not medically 
necessary as there was no indication that a presumptive drug screening was performed for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is indicated in certain 
situations.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of drug testing have not been met. Specifically, there is no documentation of a presumptive drug 
screening for this enrollee which included presumptively positive results or results which were inconsistent 
with the enrollees medical history. There is no indication that a presumptive test was not available, but the 
other criteria of the Local Coverage Determination were met. Therefore, we decided that the Plan does not have 
to pay for definitive drug testing (G0483) provided on August 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for computerized corneal topography provided on August 15, 2022. 
 
You asked the Plan to pay for computerized corneal topography. You say that this service was medically 
necessary. The Plan denied your request. The Plan says that your Plan excludes this service. 
 
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. Specifically, the Plan has not provided a Medicare rule or a Plan rule to 
substantiate their denial. Therefore, we decided that the Plan has to pay for computerized corneal topography 
provided on August 15, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast 
(77047). 
 
You asked the Plan to pre-approve an MRI of the breast. 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 must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 an MRI of the breast. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is reference to a mammogram 
which had been done which was reported to have been normal by the enrollee but no report of this 
mammogram or an ultrasound are in the records submitted.  Without such information the medical necessity of 
the requested MRI has not been established in this enrollee who had a prior benign biopsy, is BRCA negative 
and who does not have a palpable mass. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the breast have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77047).