Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92921 billed for date of service September 7, 
2022. 
 
You asked the Plan to pay for procedure code 92921. You say that the medical records support the billing, and 
the claim should be reprocessed for payment. The Plan denied your request. The Plan says procedure code 
92921 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 92921 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 92921 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 92921 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 92921 billed for date of service September 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need IRF care to get your strength back to be 
able to return home. The Plan denied your request. The Plan says criteria for admission to the IRF setting have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not require intensive physician and nursing oversight in an IRF. While you may benefit from additional 
multiple therapies, including physical and occupational therapy, the documentation does not reveal that you 
require this therapy on an intensive IRF level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair lift (E1399). 
 
You asked the Plan to pay for a stair lift. You say that the enrollee needed the stair lift in order to get up the 
stairs. Since you are choosing to stay in your home as long as possible, a stairlift is a definite necessity. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair lift (E1399).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service April 23, 
2022, to May 20, 2022. 
 
You asked the Plan to pay for procedure code S9328. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service April 23, 2022, to May 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on September 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that you provide the best services to your clients. 
The Plan denied your request. The Plan says the documentation does not support the billing criteria. 
 
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 G0482 is definitive drug testing of 15-21 drug classes. 
We find that CPT code G0482 is not supported in the medical record. Specifically, the records do not show that 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the 
billed services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on September 6, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an octreotide injection (J2353). 
 
You asked the Plan to pre-approve octreotide. You say that the requested drug is necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 octreotide. Our reviewer says that 
octreotide is not medically necessary. Our physician reviewer found that the Food and Drug Administration 
(FDA) has not stated that the requested drug is indicated for the enrollee's condition. The reviewer found that 
the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested 
drug in the enrollee's clinical situation either. Therefore, the reviewer found that the requested drug, octreotide, 
is not medically reasonable and 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 octreotide have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an octreotide injection (J2353).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service October 27, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the services should be processed at the in-
network rate. The Plan denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99100 billed for date of service October 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory service provided on September 19, 2022. 
 
You asked the Plan to pay for laboratory service. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory service 
provided on September 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the documentation does show active medical comorbidities however no complex 
functional impairments have been specified thus the complexity of the enrollee's documented nursing, medical 
and rehabilitation needs would not be expected to require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the IRF admission 
criteria, and you are requesting reconsideration based on the records submitted. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for an IRF stay. 
 
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 that the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. The enrollee continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement. However, the documentation 
does not support that the enrollee would meet criteria for admission to an IRF. The enrollee can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an IRF admission and services.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services billed for dates of service from May 26, 2022, to 
June 22, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 case record does not contain a legitimate and substantive denial 
rationale. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's denial has 
not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for home 
health services billed for dates of service from May 26, 2022, to June 22, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Apligraf application. 
 
You asked the Plan to pre-approve Apligraf application. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Chronic Wounds are defined as wounds that do not 
respond to standard wound treatment for at least a 30-day period during organized comprehensive conservative 
therapy. 
 
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 Apligraf application. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
support criteria for treatment with Carbamate-Treated Plastic Sheeting (CTPS) to the ulcer are met. There is no 
clear documentation that the enrollee has failed treatment for 30 days and there is noted to be necrotic debris or 
exudate in the wound base. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Apligraf application have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Apligraf application.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lesion removal (11403) provided on July 22, 2022. 
 
 
You asked the Plan to pay for a lesion removal. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will consider the removal of benign 
skin lesions as medically necessary, and not cosmetic, if one or more of the conditions listed in the Medicare 
Rules section is present and clearly documented in the medical record. 
 
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 a lesion removal. Our reviewer says that the 
service was not medically necessary. Our physician reviewer found there was no documentation indicating that 
the enrollee has any of the conditions listed as covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lesion removal have not been met. Therefore, we decided that the Plan does 
not have to pay for a lesion removal (11403) provided on July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an oxygen concentrator (E1390) provided on September 17, 2022. 
 
You asked the Plan to pay for an oxygen concentrator. You say that the item was medically necessary. The 
Plan denied your request. The Plan says that this service was paid to another provider for the same date of 
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. The Plan has not provided documentation, such as a remittance advice, showing 
this item was paid to another provider. Therefore, we decided that the Plan has to pay for an oxygen 
concentrator (E1390) provided on September 17, 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 a Jazzy Air2 Power Scooter (K0899), purchased on July 14, 
2022. 
 
You asked the Plan to pay for a Jazzy Air2 Power Scooter. You say that the item was medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that s power operated vehicle (POV) or power 
wheelchair (PWC) which has not been reviewed by the Pricing, Data Analysis, and Coding (PDAC) contractor 
or which has been reviewed by the PDAC and found not to meet the definition of a specific POV/PWC will be 
denied as not reasonable and necessary. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Jazzy Air2 Power Scooter have not been met. Therefore, we decided that the Plan does not have 
to pay for a Jazzy Air2 Power Scooter (K0899), purchased on July 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87798, 87640, and 87641 provided 
on December 29, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87798, 87640, and 87641. You say that the medical 
records support the use of modifier XU with codes 87150, 87798, 87640, and 87641. The Plan denied your request. The Plan says the medical records do not support the use of modifier XU with codes 87150, 87798, 
87640, and 87641. 
 
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 procedure codes 87150, 87798, 87640, and 87641. 
 
In this case, we have confirmed that code 87150 is a column II code to column I code 87500; however, 87150 
was billed with a modifier. Our reviewer found based on the documentation provided, the laboratory report 
does not include documentation to support CPT 87150 with modifier XU unusual non-overlapping service, 
from CPT 87500, as CPT 87500 includes vancomycin resistance. Therefore, modifier XU cannot be verified. 
 
We have also confirmed that code 87798 is a column II code to column I codes 87150 and 87801; however, 
87798 was billed with a modifier. Our reviewer found based on the documentation provided, the laboratory 
report does not include documentation to support CPT 87798 (not otherwise specified), with modifier XU 
unusual non-overlapping service, from CPT 87801 Infectious agent detection by nucleic acid (DNA or RNA), 
multiple organisms; amplified probe(s) technique.  In this case, a "not otherwise specified" code cannot be 
verified in the laboratory report. 
 
We have also confirmed that code 87640 is a column II code to column I codes 87150, 86741, and 87801; 
however, 87640 was billed with a modifier. Our reviewer found based on the documentation provided for code 
87640, Staphlococcus aureus is documented in the laboratory report, however, this procedure would be 
inclusive to CPT 87801 which includes multiple organisms. Therefore, XU cannot be verified. 
 
Finally, we have also confirmed that code 87641 is a column II code to column I codes 87150 and 87801; 
however, 87641 was billed with a modifier. Our reviewer found based on the documentation provided for code 
87641, Staphlococcus aureus is documented in the laboratory report, however, this procedure would be 
inclusive to CPT 87801 which includes multiple organisms. Therefore, XU cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87798, 87640, and 87641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87798, 87640, and 87641 
provided on December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 27, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 27, 2022.