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

 
We decided that the Plan does not have to pay for procedure codes 75726 and 75774 billed for date of service 
November 26, 2021. 
 
You asked the Plan to pay for procedure codes 75726 and 75774. The Plan denied your request. The Plan says 
payment for codes 75726 and 75774 is bundled into payment for code 37244.  
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 codes 
75726 and 75774 are column II codes to column I code 37244. 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 codes 75726 and 75774 billed for 
date of service November 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have been discharged from the hospital and are 
awaiting approval for IRF. You also say that you were approved for IRF prior to being admitted to the hospital. 
The Plan denied your request. The Plan says that you do not meet the criteria for admission to 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 found to be medically reasonable and necessary. Our physician reviewer found that you 
were previously accepted to inpatient rehab. It is documented by vascular surgery that you will require 
continued close monitoring of wound and peripheral pulses and would be expected to warrant inpatient 
hospitalization during rehabilitation. Evaluating therapists recommend intense therapy and you would tolerate 3 
hours of therapy per day. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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 ultraviolet light therapy system, includes bulbs/lamps, 
timer and eye protection; treatment area 2 square feet or less (E0691) provided December 6, 2022. 
 
 
You asked the Plan to pay for the ultraviolet light therapy system. You say that you disagree with the 
assessment and is appealing the denial. The Plan denied your request. The Plan says the services is not 
documented in the enrollee's medical records. 
 
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 ultraviolet light therapy system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case the documentation doesn't support that the requested item can 
be considered DME. Additionally, the requested device has not been shown to be superior to other standard 
treatments for the medical condition. The requested equipment 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 ultraviolet light therapy system have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultraviolet light therapy system, includes bulbs/lamps, timer and eye 
protection; treatment area 2 square feet or less (E0691) provided December 6, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of any joint of the lower 
extremity (73721). 
 
You asked the Plan to pre-approve an MRI of any joint of the lower extremity. The Plan denied your request. 
The Plan says that this request cannot be approved. 
 
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 did not provide medical records for this case. We asked for these 
records, but they were not provided to us. Without this information we cannot determine that requested service 
is not medically necessary, or does not meet the criteria for coverage. Consequently, the Plan has not 
substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pre-approve a 
magnetic resonance imaging (MRI) of any joint of the lower extremity (73721).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 12001 billed for date of service March 18, 
2022. 
 
You asked the Plan to pay for procedure code 12001. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 12001 is bundled into payment for code 26750. 
 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 12001 
is a column II code to column I code 26750. 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 12001 billed for date of service March 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 home health aide visits. 
 
You asked the Plan to pre-approve 12 home health aide visits. 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. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 12 home health aide visits. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical 
records provided there is no documentation that the home health aide services reasonable and necessary to the 
treatment of the enrollee's illness or injury by the skilled professional staff. The health plan denied the 
requested home health aide services stating that the medical records show that the enrollee has caregiver(s) 
who help with his daily living activities which include bathing, dressing, toileting, grooming, cleaning, and 
meal preparation. Provided records from the home health agency do not document that the enrollee does not 
have caregiver(s) who help with his daily living activities.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 home health aide visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 home health aide visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 5, 2022, to 
April 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the fax was usually busy and not working. 
The Plan denied your request. The Plan says the claim was processed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The claim information indicates a request for anticipated payment (RAP) 
was submitted. RAPs shall no longer be submitted as of January 1, 2022. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from April 5, 2022, to April 7, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay an additional amount for the inpatient hospital care provided from October 
22, 2020, to November 26, 2020. 
 
You asked the Plan to pay an additional amount for the inpatient care. You say that additional payment should 
be made. The Plan denied your request. The Plan says that the claim processed correctly. 
 
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 summary of the charges that they think 
are incorrect. Therefore, we decided that the Plan has to pay an additional amount for the inpatient hospital care 
provided from October 22, 2020, to November 26, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external patient and, when performed, auto activated 
electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days (93271) provided on May 18, 2022. 
 
You asked the Plan to pay for the cardiovascular monitoring service. You say that the procedure code used in 
this case is correct for the services you provide. The Plan denied your request. The Plan says the service in this 
case was not medically necessary. 
 
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 93271 is external patient and, when performed, auto 
activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days, 24-hour attended monitoring; transmission and analysis. 
 
We find that CPT code 93271 is not supported in the medical record. Specifically, the provided documentation indicates that the monitoring services did not exceed 48 hours. There are other monitoring codes that would be 
more appropriate to describe the service actually rendered. Based on this information, we decided that 
Medicare rules for coverage of the cardiovascular monitoring service have not been met. Therefore, we decided 
that the Plan does not have to pay for the external patient and, when performed, auto activated 
electrocardiographic rhythm derived event recording with symptom-related memory loop with remote 
download capability up to 30 days (93271) provided on May 18, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for targeted genomic sequence analysis 51 or greater genes (81455) 
provided March 14, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that FoundationOne Heme was ordered by the 
treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says that Genetic testing procedures submitted with code 
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be 
denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a diagnosis of ovarian cancer. The review has 
determined that the items/services at issue in this case are 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 the genetic testing have been met. Therefore, we decided that the Plan has to 
pay for targeted genomic sequence analysis 51 or greater genes (81455) provided March 14, 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 pay for the services (76497) provided on February 1, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the service requested is 
included in the payment for the CT scan. 
 
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 76497 is "Unlisted computed tomography procedure (eg, 
diagnostic, interventional)". 
 
We find that CPT code 76497 is not supported in the medical record. Specifically, the provider did not submit 
an imaging report. Billing an unlisted code is appropriate only if the service provided is not adequately 
described by any existing CPT codes. It cannot be determined that this is the case without a record of the 
imaging that was performed. 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 services (76497) 
provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jentadueto. 
 
You asked the Plan to pre-approve Jentadueto. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jentadueto.  
 
Benefits for Jentadueto may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a transesophageal echocardiography procedure (93355) billed for date 
of service December 1, 2021. 
 
You asked the Plan to pay for a transesophageal echocardiography. You say that you have provided records to 
support the code billed. The Plan denied your request. The Plan says that rules for payment have not been met 
because the code at issue is included in another billed code. 
 
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, the Plan has denied, stating that the code at issue is included in 
another billed code and a modifier to bypass the edit is not permitted. We found that it is permissible to bypass 
the edit at issue. Code 93355 was billed with modifier -59 which indicates a separate and distinct service. The 
Plan has not forwarded pertinent medical records to determine whether the use of modifier -59 is appropriate in 
this case. 
 
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 a 
transesophageal echocardiography procedure (93355) billed for date of service December 1, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on May 23, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test helps determine the best course of 
treatment. The Plan denied your request. The Plan says that there is no documentation to support the testing on 
the billed 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. 
 
We looked at the file and the rules. The Plan has not shown that the sample at issue has not met one of the 
exceptions for the billed date of service. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for the laboratory services provided on May 23, 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 pay for the acute inpatient hospital care provided from February 8, 
2022, to February 20, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, 
the reviewer found that the inpatient admission was 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 8, 2022, to February 20, 
2022.
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 LTACH is the safest, most efficient 
level of care based on the enrollee's complexity and history. The Plan denied your request. The Plan says the 
LTACH is not medically necessary, and the enrollee's needs are being met at the current acute hospital until the 
enrollee can discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with chronic obstructive 
pulmonary disease (COPD) exacerbation and pneumonia requiring steroids, antibiotics, BiPAP, high flow 
oxygen support and bronchodilators. The enrollee appears to be more stable and improving and should only 
require short-term additional acute care hospital services that can safely be administered at the current facility 
until more appropriate for a lower level of care. The enrollee does not require services at the LTACH that are 
not already available at the current 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 long term acute care hospital (LTACH) services.