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 the enrollee cannot be safely discharged home. The 
Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. 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. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A4550 and S0020 billed for date of service 
December 7, 2022. 
 You asked the Plan to pay for procedure codes A4550 and S0020. You say that these services are supported in 
the medical record. The Plan denied your request. The Plan says procedure code A4550 is considered bundled 
and not separately payable. In addition, procedure code S0020 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 A4550 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code A4550 is not separately payable. In addition, we find that procedure code S0020 has a status 
indicator of I on the Physician Fee Schedule. This means that procedure code S0020 is not valid for Medicare 
purposes. Based on this information, we decided that Medicare rules for coverage of procedure codes A4550 
and S0020 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
A4550 and S0020 billed for date of service December 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 22, 2022, to 
November 20, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that You say that a system issue with 
your electronic claim vendor caused the date of admission to be incorrect on the claim. 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 October 22, 2022, to 
November 20, 2022.  
 
Please note that you indicated in additional information you submitted to us that you have discovered the 
billing issue with the admission date on the claim and have submitted a corrected claim.  This corrected claim 
has not, to our knowledge, been received or adjudicated by the Plan.  Please contact the Plan directly regarding 
the submission of your corrected claim.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 80053, 80061, 83036 and 85025 billed for 
date of service June 29, 2022. 
 
You asked the Plan to pay for procedure codes 80053, 80061, 83036 and 85025. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says the billed code is a statutory 
exclusion. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure codes 80053, 80061, 83036 and 85025 have a Status Indicator of X on the Physician 
Fee Schedule. This means that procedure codes 80053, 80061, 83036 and 85025 are a statutory exclusion. 
Based on this information, we decided that Medicare rules for coverage of procedure codes 80053, 80061, 
83036 and 85025 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 80053, 80061, 83036 and 85025 billed for date of service June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital care (procedure codes 99223 and 99233) rendered 
from December 9, 2022, to December 11, 2022. 
 
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 review determined the billed services were not supported. 
 
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 the denied codes is: 
 
CPT 99223: 
 
Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit 
 
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 the documentation does not show 
evidence of a detailed interval history or medical decision making of high complexity for the dates of service at 
issue in this case. 
 
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 hospital care (procedure codes 99223 and 99233) rendered from December 9, 2022, to 
December 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 23, 2023. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says panel 
testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection. 
 
You asked the Plan to pre-approve a sacroiliac joint injection. You say that this is necessary to decrease the 
enrollee's pain. The Plan denied your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that sacroiliac joint injections (SIJI) will be 
considered medically reasonable and necessary when there is documentation of at least three positive findings 
with provocative maneuvers: FABER, Gaenslen, Thigh Thrust or Posterior Shear, SI Compression, SI 
Distraction and Yeoman Tests. 
 
We looked at the file and Medicare rules. The submitted records do not include documentation of at least three 
positive findings with provocative maneuvers. Based on this information, we decided that Medicare rules for 
coverage of a sacroiliac joint injection have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a sacroiliac joint injection.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab testing codes U0004 and U0005 billed for date of service March 24, 
2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that a CS 
modifier should be billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
We looked at the file and the rules. The guidelines require the CS modifier for COVID-19 testing related 
services. The guidelines do not indicate that the CS modifier is also required for the lab tests at issue. Based on 
this information, we decided that Medicare rules for coverage have been met. Therefore, we decided that the 
Plan has to pay for lab testing codes U0004 and U0005 billed for date of service March 24, 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 pre-approve an upright walker (E0143). 
 
You asked the Plan to pre-approve the services. You say that a cane is not sufficient. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that you have lumbar spine pain, and lumbar spinal stenosis. You were referred to physical therapy as 
well as an evaluation for spinal surgery. You were also provided with medication for pain relief. You were 
ordered a walker for assistance with mobility. However, your level of mobility and function in terms of 
performing daily activities is not documented as well as if you can safely use a walker. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upright walker (E0143).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria. The Plan denied your request. The Plan says that the enrollee does not meet all of the 
requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and are 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 LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a polysomnography (95810). 
 
You asked the Plan to pre-approve a polysomnography. The Plan denied your request. The Plan says this 
request is not medically necessary because you have good response with CPAP and no new changes in your 
condition. The Plan also says that a diagnostic sleep study would not provide any new information, as you have 
an established diagnosis which is responding well to appropriate treatment. 
 
The Plan follows Medicare rules. Medicare rules say that if a PAP device is replaced following the 5-year 
RUL, there is no requirement for a new sleep test or trial period. 
 
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 a polysomnography. Our reviewer says 
that a polysomnography is not medically necessary. Our physician reviewer found you were diagnosed with 
obstructive sleep apnea 20 years ago, and have been on CPAP since then. The device is more than 6 years old, 
and you are requesting a new device. Our reviewer found that the device is effective in treating your sleep 
apnea symptoms. The records do not include a device download. Our physician reviewer also found that a 
repeat polysomnography is not necessary in order to provide you with a new CPAP device if the current device 
is effective in treating your sleep disordered breathing, as it appears to be in this case. 
 
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 polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a polysomnography (95810).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided on January 10, 2023, 
to January 17, 2023, 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 A41.9. 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 A41.9 is not supported by the records provided. Our physician 
reviewer found that there was no clinical or laboratory evidence of sepsis. Therefore, the documentation did not 
support diagnosis code A41.9.  
 
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 January 10, 2023, to January 17, 2023, at the Diagnosis Related 
Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a pneumatic compression device (E0675). 
 
You asked the Plan to pay for  a pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for  a pneumatic compression device (E0675).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for dental services provided on February 6, 2023. 
 
You asked the Plan to pay for dental services. You say that this should be covered. The Plan denied your 
request. The Plan says that the amount charged is correct. 
 
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. there is no documentation showing the full processing of the claim including 
what the enrollee was charged and without that we cant determine what the plan charged them is correct. 
 
 Therefore, we decided that the Plan has to pay for dental services provided on February 6, 2023.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483, 80307) provided on February 
23, 2023. 
 You asked the Plan to pay for drug testing. You say that these services were medically necessary and are 
supported in the medical records. The Plan denied your request. The Plan says there is insufficient 
documentation to support the necessity of these services. 
 
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 drug testing have been met. 
Specifically, the records provided do not include a test order/requisition form to support that these tests were 
requested by a physician who is treating the enrollee. Therefore, we decided that the Plan does not have to pay 
for drug testing services (G0483, 80307) provided on February 23, 2023.